C&C Probity Homecare Services LLC
Job Application
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Social Security Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What position are you applying for?
*
Caregiver
Other
Have you ever been charged with a felony or misdemeanor? If hired, you will be required to do a background check?
*
YES
NO
If yes, please explain
Please select all that apply to you
*
CPR Certification
Recent copy of TB
Valid Drivers License
Car Insurance
HHA Certification
CNA Certification
COVOID-19 Vaccination
Please upload a copy of Driver's License or ID
*
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of
Please upload a copy of your Social Security card
*
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Please upload CPR and TB Shot documents
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Please upload any other relevant documents
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What specific shift/hours are you looking to work?
*
How many hours do you want to work a week?
*
Are you willing to work weekends?
*
Every
Rotating
None
Are you willing to travel? How fare?
*
( We have clients in Hamilton, Hendricks, Johnson, Marion)
I am comfortable (select all that apply)
being around dogs
being around cats
being around pets
being around cigarette smoke
with showering/bathing clients
with hoyer lifts
with transferring clients i.e. bed to chair
Do you have a valid driver's license?
*
YES
NO
Do you have a car? (may need to run an errand for clients or transport clients)
*
YES
NO
Do you have car insurance?
*
YES
NO
Please list 1 professional reference- Name, Phone number, brief description of Relationship.
*
Please list 1 personal reference- Name, Phone number, brief description of Relationship.
*
If you are coming with a client please list client name and relationship to you. i.e. Jane Doe Mother
If you were referred by an employee or client, please list their name below
Submit
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